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APPLICATION FOR SANITATION PERMIT Permit No. _-- _'1--.- --. (Complete in Duplicate) Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. + This application is made in compliance with County Ordinance No. 549. l �* ------------- ------------------------•-- JOB ADDRESS AND LOCATION-- --/--- Owner's Name----- 4A-.----- " ----------- -- ---- Phone------------------------------------ ---------------------- -------------------------------------------- ---•------------------------------•----- Address _ ---•---•-------------------------- .49 t Prone. Contractor's Name.---------- - Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ IF A, Number of living units: I--- Number of bedrooms Number of baths _4-_ Lot size -----c-,X929- ---A-4040--------------------------- Water Supply: Public system �Commun'ity system El private ❑ Depth to Water Table Y.4 ft Character of soil to a depth of 3 feet: `Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe A'Hardpan ❑ Previous Application Made: Yes ❑ No k`_ New Construction.: Yes ❑ No �FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or`cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well------------------Distance from foundation---------------------Material ----_---_-----------_---__------_-_-----_------. ❑ No. of compartments------------- -----------Size-_.-----------------------------Liquid depth "-----------------------Capacity-------------------- Disposal Field: Distance from•nearest well....... ._Distance from foundation--------------------Distance to nearest lot line-"----------___-- ❑ Number of Fines----------%-------------- ---- "__Length of each line-----------------------------.-..Width of trench--------------------------------- Type of filter mateirial_-�`--------------------Depth of filter material-----------------------Total length------------------------------------------ de A Seepage Pit: Distance to nearest well-7WV7� -._Distance from foun tion---aZ9------..Distance to nearest lot line------�'--__-_ F� f lNumber of p ts---- -------------Lining materialf -- - .. Size: Diameter--sd _-.--- Depth---- --_--------_--_ Cesspool: Distance from nearest well---------------- Distance from foundation--------------------Lining material___-----------"-----______---------. ❑ Size: Diameter-------------------------- <---------Depth------------------------------------ --------------Liquid Capacity----------------------------gals.\) Privy: Distance from nearest well-- ------------------ --- -------- ------Distance from nearest building---------- ----------------------------- Distance _-----__-----_-_----- -Distance to nearest lot line ---------------------------------------------------------------------------------------- - --•-------- Remodeling and/or repairing (describe)-------- - — -- ----------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------ --------------------------------------- - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and r guI tions of the San Joaquin Local Health District. (Signed) -- a �°r Contractor) Sy:---------------•------------- ------(Title)-= ��1` (Plot plan, showing size of I location of system in relation to wells, buildings, etc., can be placed on revers side]. FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY---------------------------- -------------- ---------------------------------- DATE ---------�2' --------------------- REVIEWED BY --- DATE------------------ - ------------------------------------ -------------- -------------------- -- --- BUILDING PERMIT ISSUED--------------------- --- - --- DATE-- --- --- ----------------------------- Alterations and/or recommendat'ons:--- - --- -"_------_____ --- ----------- ----------- ------ --------------------------- --------------------------•------- ��",.---- -- -- - _ ----------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------ - ----- --------------------------------- --------- FINAL INSPECTION BY:--- /+ ---- ----- Date---- -- -- - ------ --------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT r 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California — Lodi, California Manteca, California Tracy, California E5-9-2M Revised ).57 F.P.CO.